CARE HOMES FOR OLDER PEOPLE
Bullsmoor Lodge 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE Lead Inspector
Tony Brennan Unannounced Inspection 12th January 2006 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bullsmoor Lodge Address 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01992 719092 01992 650603 Scimitar Care Hotels Plc Angela Christine Carter Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th September 2005 Brief Description of the Service: Bullsmoor Lodge is a modern purpose built home owned by Scimitar Care Hotels. There are four homes belonging to this organisation. The home is registered to care for forty-eight people of either gender who are over the age of sixty-five. Bedrooms are located on three floors. The main lounge, dining room and kitchen are on the ground floor. All but three rooms are single and have en-suite toilets. There is an attractive garden to the rear of the house. There are two lifts that give access to all floors. The home aims to provide support and care in a homely environment. Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the four areas for improvement found at the last inspection were addressed. The inspection took place over one day. The registered manager assisted the inspector. The inspector spoke with four people who live at the home, three relatives and three staff. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: What has improved since the last inspection? What they could do better:
Seven areas for improvement were identified at this inspection. People living at the home said that they had not been consulted about the care and support they received Care plans need to provide information on how the needs of those living at the home are to be met. Two people who recently came to live at the home had no risk assessments and prevention plans for falls that had been identified as a risk in their initial assessments. The records of medicines administered had gaps where administration had not been recorded. The registered manager explained that not all staff had been receiving regular supervision. There had not been a survey of the views of people who live at the home and other stakeholders of the quality of the service. Automatic door closures need to be installed on all those bedroom doors where the person wishes to keep it open. Four requirements made at the last inspection have not yet been met and have been restated in this report, with a new timescale for compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission
Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 6 for Social Care Inspection considering enforcement action to secure compliance. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A These standards were not inspected on this occasion. EVIDENCE: Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Care plans did not provide sufficient information on how the needs of service users would be met and they had not been consulted about the contents of the plans. Service users risk of falls had not been assessed. Service users privacy is maintained. EVIDENCE: Service users and relatives said that they had not been consulted about the contents of care plans. The inspector saw that care plans still did not show any evidence of consultation with service users or their representatives. The inspector saw care plans for two new service users; these did not provide detailed information on how their needs will be met. These service users had a risk of falls identified on their initial assessments, but the home had not assessed this risk or put a prevention plan in place. The inspector examined the medication administration records and found that there were significant gaps in recording. This was identified at the last inspection and an immediate requirement was given. Service users said that staff respect their privacy and always knock on their bedroom doors. Service users also said that staff take time to ask how they wished to be assisted. Staff understood how to assist service users in a way
Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 10 that ensures that their privacy is maintained. The inspector observed staff interaction with service users and found that they were accorded respect. Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 Service users are provided with sufficient and varied activities to meet their needs. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. EVIDENCE: Service users said they had been provided with activities and entertainment. The interests of service users had been recorded and activities that had been provided were recorded. Service users mentioned that there had been film afternoons, movement and music, card games and hairdressing. The registered manager explained that she was intending to consult an occupation therapist about suitable activities. Service users spoken to confirmed they had a choice as to whom they wished to see. Service users and relatives also said that there were no restrictions on visiting times. Service users and relatives also felt that staff were supportive and would assist them to spend time privately if they wished. Service users spoken to confirmed that they could make choices and control their lives, for example, choices of food and whether they wished to participate in activities. Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A None of these standards were inspected on this occasion. EVIDENCE: Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A None of these standards were inspected on this occasion. EVIDENCE: Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A None of these standards were inspected on this occasion. EVIDENCE: Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 38 Service users live in a home that is well managed. Service users are not consulted about the quality of the service provided. Service users financial interests are protected by the home’s procedures. Staff are not appropriately supervised to ensure that the needs of service users are met. Service users are not protected against the risk of fire. EVIDENCE: Relatives and service users said they felt that the registered manager was supportive and listened to them. The registered manager explained that she is currently doing the RMA. The registered manager explained that she has maintained her training and has over 15 years relevant experience. Service users spoken to say that they were consulted through regular meetings about the quality of the service provided. There is also a record of comments made about the service. The registered manager explained that no survey had been carried out of the views of service users or relatives of the quality of care provided by the home.
Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 16 The registered manager explained that the home does not manage service users finances. Families or representatives manage finances. A number of service users with the support of staff, manage their own finances and were necessary are supported to go to the bank. Systems were in place to ensure that this was done safely. The registered manager explained that she has started doing supervision, but has not managed to supervise all staff. This was discussed with the registered manager and she will be looking into arranging supervision training for other senior staff so the supervision load can be shared effectively. The inspector saw that self-closure devices still needed to be fitted to the bedroom doors of those service users who choose to have their door open. Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The registered persons must ensure that care plans have sufficient information on the action to be taken to meet the needs of service users. The registered persons must ensure that service users and their representatives are consulted about the contents of the care plans and that this is recorded. (The timescale of 01/12/05 was not met). The registered persons must ensure that service users at risk of falling are assessed and where they are at risk a prevention plan is put in place. The registered persons must ensure that the administration of medicines is recorded. The timescale of 01/12/05 was not met. An immediate requirement was given). The registered persons must ensure that a survey of service users, relatives and professionals is carried out to determine their views of the quality of the service provided. An action plan
DS0000010662.V269909.R01.S.doc Timescale for action 01/04/06 2 OP7 15(1) 01/04/06 3 OP8 13(4)(c) 01/06/06 4 OP9 13(2) 12/01/06 5 OP33 35(a) 01/06/06 Bullsmoor Lodge Version 5.0 Page 19 6 OP36 18(2) 7 OP38 23 must be prepared for any areas of improvement identified in the survey. The registered persons must ensure that all staff receive supervision at least six times a year. (The timescale of 01/12/05 was not met). The registered persons must ensure that bedroom doors are fitted with self-closure devices where service users choose to have them open. (The timescale of 01/11/05 was not met). 01/04/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bullsmoor Lodge DS0000010662.V269909.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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